Provider Demographics
NPI:1326104001
Name:LICHTENWALTER, MARY KATHLEEN (LMHC, CAP, CCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:LICHTENWALTER
Suffix:
Gender:F
Credentials:LMHC, CAP, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 MARILYN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-5123
Mailing Address - Country:US
Mailing Address - Phone:386-795-7996
Mailing Address - Fax:
Practice Address - Street 1:3930 S NOVA RD STE 307
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9293
Practice Address - Country:US
Practice Address - Phone:386-795-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLCAC 870056A101YA0400X
IN39001980A101YM0800X
FLCAP 5276101YA0400X
FLMH10712101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196900AMedicaid